Public policy

In 2010, the United States struck a major blow against HIV-related stigma by officially lifting the HIV entry ban that restricted non-U.S. citizens with HIV from entering the country. The policy was deemed to be outdated and discriminatory and to stigmatize people living with HIV, the majority of whom are gay men in the United States. The public health community, HIV advocates and people living with HIV hailed the action as a significant step forward in the international and domestic fights against the stigma of HIV. Once the HIV-entry ban was lifted, the way was paved for locating the 2012 International AIDS Conference in Washington D.C., the first time the conference has been held in the U.S. in more than 20 years. Both actions brought awareness to the stigmatizing effects public law and policy can have on people living with HIV/AIDS.

The U.S. federal government has long regarded gay-related and HIV-related stigma as sociocultural forces that ought to be considered in the design and implementation of HIV prevention programs. The Centers for Disease Control and Prevention (CDC) provides funds to state and local health departments and nongovernmental organizations for public information and HIV/AIDS awarenessraising activities. These activities are meant to educate the public at large about HIV/AIDS and also to counter negative connotations society attributes to HIV-positive gay men. However, the impact that these and other federally funded programs have on reducing societal stigma toward gay men is unclear. Renewed attention to the domestic epidemic and the resurgence of HIV among gay men combine to create an environment for renewed consideration of public policy approaches that can advance positive change in this area.

Efforts are now under way to better understand how gay-related stigma and homophobia are related to HIV transmission and HIV-related health outcomes and to determine the best public policies to respond to these challenges. For example, the third goal of the National HIV/AIDS Strategy (NHAS; White House Office of National AIDS Policy, 2011) — to reduce HIV-related health disparities and health inequalities — addresses stigma. The NHAS recognizes that HIV status is often related to stigma and discrimination in employment, housing and access to health care and to public accommodations. Systemic discrimination can impede the desire and ability of persons living With HIV to get tested, seek care and treatment and effectively manage their HIV disease.

NHAS calls for the vigorous enforcement of the Americans With Disabilities Act, the Fair Housing Act and the Rehabilitation Act. Enhanced enforcement of these three laws will combat discrimination by creating an environment in which HIV/AIDS testing and treatment are not socially punished. In addition, the NHAS suggests that older laws directed specifically at HIV/AIDS–positive individuals (such as those linked to consensual sexual behavior, spitting and biting) be reconsidered. These laws are based on outdated information and support inaccurate conceptions surrounding HIV/AIDS that can discourage individuals from seeking testing and treatment.

The CDC also recognizes the importance of addressing stigma and discrimination in HIV prevention and strategies to reduce health inequities across several disease conditions. In its 2010 White Paper on Social Determinants of Health (PDF, 2.8MB), the CDC outlined a plan for reducing health disparities related to HIV, STDs, TB, and viral hepatitis. The CDC identified “social environment” (which includes discrimination) as one of the five main determinants of population health and therefore as one of the foci of their activities. The white paper only includes one priority specifically related to reducing stigma and discrimination toward HIV-positive individuals. This priority aims to generate both culturally and linguistically relevant information that addresses factors which create or reinforce stigma and discrimination of persons with HIV/AIDS, sexually transmitted infections, tuberculosis and hepatitis.

Both of the aforementioned documents acknowledge the impact of stigma and discrimination in HIV prevention, but neither lays out a far-reaching path. They exemplify the lack of specificity in the federal response to gayrelated stigma, which may be due to limitations in the research on and evidence-base regarding the health needs of gay men. A recent Institute of Medicine (2011) report concluded that there is a lack of research surrounding the health needs of the lesbian, gay, bisexual, and transgender (LGBT) community and recommended the implementation of a research agenda to assist the National Institutes of Health (NIH) in enhancing its research efforts in LGBT health.

Laws and policies at the state level are also relevant. The National Alliance of State and Territorial AIDS Directors (NASTAD, 2011) recently called for the repeal of HIV-specific criminal statutes because such state-level laws foster and sustain stigma and discrimination against individuals living with HIV/AIDS. According to NASTAD, 34 states and 2 U.S. territories explicitly criminalize HIV exposure through sex, shared needles or, in some states, exposure to “bodily fluids” that can include saliva. These laws may impede individuals from learning their HIV status and from disclosing their HIV status to sexual and/or needle-sharing partners. The NHAS encourages state legislatures to review punitive HIV-specific criminal laws to ensure that they are consistent with current knowledge about HIV transmission and grounded in sound public health principles.

Current plans that may potentially reduce gay-related stigma are vague and incomplete. Researchers agree that more information is needed to better define how stigma impacts HIV transmission among gay men and how it impacts their ability to access culturally competent care and treatment. The NHAS creates an opportunity for reassessment of all domestic HIV/AIDS prevention and care programs with respect to their contribution to meeting the strategy’s goals and realignment of some domestic HIV/AIDS spending. Strategies that may potentially deserve new and/or enhanced funding include community mobilization strategies that encourage positive attitudes toward sexual orientation and gender identity; interventions that encourage disclosure of gay identity and HIV status; and development, adaptation and implementation of communitylevel and structural interventions to address gayrelated stigma.

Several action steps can be taken to address the barriers of gay-related stigma and discrimination in HIV prevention:

Invest in research to develop and test the effectiveness of interventions designed to address HIV-related disparities attributable to stigma, homophobia and discrimination. NIH and CDC should include such studies in their research portfolios.

Rapidly evaluate and scale up program initiatives with evidence of effectiveness aimed at addressing gay-related stigma. Such programs would include U.S. Department of Health and Human Services (HHS) public information campaigns, awareness-raising activities, community mobilization strategies and capacity-building initiatives. Evaluation findings should be disseminated to policymakers and diverse stakeholder groups and should be used to modify, tailor, expand or eliminate programs based on evaluation findings.

Fully implement NHAS action steps that respond to gay-related stigma. Action steps in the NHAS are to engage communities to affirm and support people living with HIV; promote leadership of people living with HIV; promote public health approaches to HIV prevention and care on the state level, including revisiting HIV-specific criminal statutes; and strengthen enforcement of federal antidiscrimination laws. Each of these is a good first step. Government alone cannot carry the burden of fully addressing the complexity of these issues. Foundations, corporate donors and other philanthropic groups should work with the public sector across all levels of government to set realistic goals and timelines for ending discrimination, stigma and homophobia. The test will be implementation. Fortunately the NHAS commits rigorous evaluation reporting requirements, which will allow stakeholders to closely monitor and assess progress.

Support enactment of the the REPEAL HIV Discrimination Act (H.R.3053), introduced by Rep. Barbara Lee (D-CA) during the 112th session of Congress. This bill calls for a review of existing federal and state laws and regulations related to the criminalization of HIV/AIDS transmission, the results of which would be presented to Congress along with recommendations for amending current laws. There is growing empirical evidence that unduly punitive laws undermine efforts to prevent HIV transmission. Criminalizing behaviors that cause HIV transmission produces negative consequences, including increased stigmatization and discrimination and the avoidance of voluntary testing. The review and reform of current HIV criminalization statutes detailed in H.R.3053 will help to reduce the HIV/AIDS-related stigma that undermines health initiatives focused on screening, prevention and treatment. Recent developments in international HIV policy can inform domestic responses to gay related stigma.

The Global Forum on MSM (MSMGF) and HIV has spearheaded a robust global conversation about social discrimination against gay men and its implications for HIV prevention. In 2010, the MSMGF issued policy recommendations that included increasing investment in gay men and HIV-related anti-stigma work, developing an evidence base on stigma against gay men, and improving methods to map and measure gayrelated stigma. While civil society across the globe engages, many are now questioning the interest of U.S.-based LGBT-centered advocacy organizations in addressing HIV prevention among gay men. Policymakers and stakeholders interested in addressing gay-related stigma here at home can learn and borrow ideas from our international colleagues. This issue of Psychology & AIDS Exchange shows psychology’s contributions to understanding how gay-related stigma contributes to disproportionate rates of HIV transmission among gay men. As such, it reminds us of the importance of understanding the national HIV/AIDS policymaking process across all levels of government — including the White House, HHS, other cabinet-level agencies, as well as state and local public health agencies — and the benefit of meaningful involvement of governmental organizations and advocacy groups in HIV policymaking processes.